大動脈瘤外科治療の経験 : 苦闘から勝利へ

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From 1965 to the end of 1995, 776 surgical operations were performed for the treatment of aortic aneurysms, and the experiences were described. Earlier than 1965, the quality of aortic surgery performed at the Heart Institute of Japan was poor. For example, after surgical repair in 9 patients with atypical coarctation of the aorta, 7 patients died of anastomotic insufficiency or bleeding. Until 1970, the operative mortality of aortic aneurysms was 45.7%. From 1970 (when I returned from a three years' stay in the U.S.A.) to 1975, the operative mortality was reduced to 24.5%, due to the use of several new inventions. Until 1990, the mortality every five years was around 10%. However, the number of patients needing aortic aneurysm repair has been increasing yearly. During the most recent five-year period, from 1991 to 1995, the mortality was reduced to 3.5%. In 1995 the mortality went down tozero. The surgical results of each aortic segment were as follows: until 1972, an ascending aortic aneurysm, especially annuloaortic ectasia, was operated upon in 11 patients, with 6 postoperative deaths (54.5%). From 1972 to 1995, using Bentall's technique, the operative mortality was reduced to 5.4% (129 operations with 7 deaths), and from 1991 to 1995, the mortality was zero, after 61 operations. The surgical results of aortic arch aneurysms were poor until 1984, but since 1985 they have improved greatly, due to use of deep hypothermia and selected cerebral per fusion (mortality 21.1%). Since 1991, retrograde cerebral per fusion and graft exclusion techniques have been employed, resulting in a marked improvement of the surgical results. During the latest five-year period, the mortality rate was 8.3% (5/60). No deaths occurred during the 40 most recent operations. Few problems have been encountered during operation on aneurysms of the descending thoracic aorta. Among 54 operations, 4 deaths occurred during the early stage of surgical experience (mortality 7.4%). The first successful surgical repair of aneurysm of the thoracoabdominal aorta in Japan was performed in 1966, at our institute. Since then, 49 patients have been treated surgically for this aneurysm, with 3 postoperative deaths (6.1%). Several adjunctive tehcniques have been employed, including mild hypothermia, temporary long external bypass, femoro-femoral bypass, and left heart bypass. Most recently, the left heart bypass equipped with a small artificial lung and heat exchanger markedly reduced troublesome events during anesthesia and the perioperative stage, and improved operative safety. Among 283 patients operated upon for aneurysms of the abdominal aorta, there were 12 deaths (4.2%). During the most recent five-year period, 119 operations were performed, including 14 on patiens with ruptured aneurysm, but there were no deaths. Of dissecting aortic aneurysms, 213 operations were performed with 40 postoperative deaths (18.8%). During the initial 11 years, from 1965 to 1975, 18 operations resulted in 13 deaths (72.2%). From 1976, the operative mortality for every five-year period was between 16% and 20%. From 1991 to 1995, 73 operations resulted in 4 deaths (5.5%); among these, 14 were of the acute type with no postoperative deaths. These excellent results were, in a great part, due to the enthusiastic cooperation of cardiologists. The improvement in the surgical results of aortic aneurysms is due to several causes. Mild hypothermia was used in the initial surgical stage, now revived as deep hypothermia. Bentall technique (graft inclusion technique) made massive bleeding easily controllable. The availability of a zero-porosity artificial graft allowed for technical ease and safety of the open distal anastomosis and the graft exclusion technique. Among adjunctive procedures, temporary long external bypass, cardioplegia for myocardial protection, deep hypothermia with selected cerebral per fusion, retrograde cerebral per fusion, and left heart bypass with a small artificial lung and heat exchanger are noteworthy. Moreover, the close cooperation which was attained between the cardiologists and cardiac surgeons, and the excellent surgical team, which allowed for a less tense atmosphere even in the most adverse conditions, proved invaluable.
東京女子医科大学の論文
1996-10-25

大動脈瘤外科治療の経験 : 苦闘から勝利へ

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